Nokea
Felicia's family is concerned because Felicia states that she is hearing voices. This is a sign of
- A. Bipolar disorder.
- B. Schizophrenia.
- C. Panic disorder.
- D. Bulimia nervosa.
Correct Answer: B
Rationale: Auditory hallucinations are a hallmark symptom of schizophrenia.
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A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
- A. Do you have trouble breathing or chest pain?
- B. Are you able to walk upstairs without fatigue?
- C. Do you awake with breathlessness during the night?
- D. Do you have new-onset heaviness in your legs?
Correct Answer: B
Rationale: The correct answer is B because assessing the client's ability to walk upstairs without fatigue helps determine the extent of heart failure. This question assesses the client's functional capacity and exercise tolerance, which are key indicators of heart failure severity. If the client experiences fatigue while walking upstairs, it indicates decreased cardiac output and potential heart failure progression. Other choices are incorrect as they focus on symptoms (A), nocturnal dyspnea (C), and peripheral edema (D), which may be present in heart failure but do not directly assess the extent of heart failure like exercise tolerance does.
What is the term used for assessment data that the patient tells you about?
- A. Focused
- B. Objective
- C. Subjective
- D. Comprehensive
Correct Answer: C
Rationale: The correct answer is 'Subjective.' Subjective data includes patient-reported symptoms, feelings, and experiences.
You are reviewing the drug list of an elderly client who is on several medications prescribed by different specialists for various health problems. The client reports 'lately there has been a roaring sound in my ears.' You notify the prescriber of which medication?
- A. gentamicin sulfate (Garamycin)
- B. metoprolol (Lopressor)
- C. amoxicillin (Amoxil)
- D. warfarin (Coumadin)
Correct Answer: A
Rationale: Gentamicin is an ototoxic medication that can cause tinnitus or hearing loss, warranting notification of the prescriber.
Which nursing diagnosis is appropriate for a client on a fluid restriction?
- A. Excess fluid volume related to intake that exceeds fluid loss
- B. Altered comfort: dry mouth and thirst related to restricted oral fluid
- C. Risk for impaired skin integrity related to compromised circulation secondary to edema
- D. Fluid volume deficit secondary to dehydration
Correct Answer: B
Rationale: A fluid restriction often leads to dry mouth and thirst, making 'Altered comfort' the most relevant nursing diagnosis.
Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is
- A. vital signs.
- B. surgical site.
- C. respiratory adequacy.
- D. level of consciousness.
Correct Answer: C
Rationale: Respiratory adequacy is critical immediately postoperatively to ensure oxygenation and ventilation.